NEWSLETTER
May 2025

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​Overcoming Communication Barriers to Improve Patient Safety for American Sign Language Users Who Are Deaf or Hard of Hearing

In the United States, approximately 3.6% of the population—about 11 million individuals—are deaf or hard of hearing1 and about 1 million adults who are deaf or hard of hearing use American Sign Language (ASL) to communicate.2 Patients who use ASL can encounter communication- related patient safety challenges in various healthcare settings.3-6 While some of these patients can use alternatives to ASL to communicate, such as lipreading or written communication methods,3,7 these are considered inferior to using ASL interpreters.7,8 For example, lip-readers may only understand part of a conversation7,9 and written communication could be limited by other factors, such as education and literacy challenges.10 Addressing these communication challenges can improve confidence in care provided, patient understanding, and—ultimately—patient safety.
 
Reports recently submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) highlight communication challenges faced by deaf or hard-of-hearing patients and the healthcare workers serving them, emphasizing that inadequate or delayed interpreter availability could lead to serious patient safety events. For example, one report described a delay in emergency department triage due to an inability to obtain an ASL interpreter and having to resort to written communication to triage a patient who was deaf. Another report described a patient who was restrained due to movement during necessary scans that resulted in the patient becoming agitated and experiencing a skin tear trying to remove the straps; this patient was deaf and may have been unable to communicate while restrained. Additionally, a patient who had limited eyesight in addition to being deaf required an in-person ASL interpreter, but only video remote interpretation (VRI) was available.

While in-person interpretation and VRI services can mitigate the communication challenges that patients who are deaf and hard of hearing can encounter, it is important to understand the limitations of these services. For example, in-person interpreters may not be available at all facilities or at all times.5 VRI services are preferred over lipreading or written communication,3,7,8,10 but technology or equipment failures may impact their availability.3,5

Patients who are deaf or hard of hearing may feel frustrated, overwhelmed, and frightened when experiencing communication challenges with their providers.5 To improve patient safety and communication, healthcare providers should consider the following practices identified through research, legislation, and advocacy groups:

  • Provide an ASL interpreter to patients who are deaf or hard of hearing, as mandated by the Americans with Disabilities Act11 and Affordable Care Act.5,12
  • Encourage patients to communicate their deaf or hard-of-hearing status to every healthcare team member.13
  • Use of VRI services may be adequate for some patients; however,
  • in-person interpreters are preferred3 and may be necessary, for example, for patients who also have vision loss.13
  • Use qualified14 interpreters5 (i.e., certified through the Certification Commission for Healthcare Interpreters15 or another certification agency).
  • Use the teach-back method16 when giving instructions to ensure patient understanding.3,13
  • Provide and use visual aids, such as written instructions or explanations of procedures, anatomical models, and posters to enhance patient understanding.3,13
  • When possible, arrange ASL interpreters ahead of time to be available to communicate with patients who are deaf or hard of hearing.4
  • Write in large, bold letters that can be read from several feet away if written communication is necessary.13
  • Allow extra time for communication13 and verification of patient understanding.
  • Involve patient family members to support communication and advocate for the patient. However, family members should be used in addition to and not in place of qualified interpreters.13
​It is important to address communication barriers for patients who are deaf or hard of hearing and communicate via ASL. Providing access to qualified ASL interpreters, using visual aids, and other evidence-based practices are essential to foster an inclusive environment and improve patient safety.
​

References

  1. National Deaf Center. How Many Deaf People Live in the United States. NDC website. https://nationaldeafcenter.org/faq/how-many-deaf-people-live-in-the- united-states/. Updated March 28, 2024. Accessed March 2025.

  2. Mitchell RE, Young TA. How Many People Use Sign Language? A National Health Survey-Based Estimate. J Deaf Stud Deaf Educ. 2022;28(1):1-6. Epub 2022/11/25. doi:10.1093/deafed/enac031; PubMed PMID: 36423340.

  3. Hommes RE, Borash AI, Hartwig K, DeGracia D. American Sign Language Interpreters Perceptions of Barriers to Healthcare Communication in Deaf and Hard of Hearing Patients. J Community Health. 2018;43(5):956-61. Epub 2018/04/27; doi:10.1007/s10900-018-0511-3; PubMed PMID: 29696596

  4. Buning GE, James TG, Richards B, McKee MM. Self-Reported Accommodation Needs for Patients with Disabilities in Primary Care. Jt Comm J Qual Patient Saf. 2024;50(1):59-65. Epub 2023/12/06; doi:10.1016/j.jcjq.2023.10.012; PubMed PMID: 38052659

  5. James TG, Coady KA, Stacciarini JR, et al. “They’re Not Willing To Accommodate Deaf Patients”: Communication Experiences of Deaf American Sign Language Users in the Emergency Department. Qual Health Res. 2022;32(1):48-63. Epub 2021/11/27; doi:10.1177/10497323211046238; PubMed PMID: 34823402

  6. Giles SJ, Lewis PJ, Phipps DL, et al. Capturing Patients’ Perspectives on Medication Safety: The Development of a Patient-Centered Medication Safety Framework. J Patient Saf. 2020;16(4):e324-e39. doi:10.1097/PTS.0000000000000583

  7. Alexander A, Ladd P, Powell S. Deafness Might Damage Your Health. Lancet. 2012;379(9820):979-81. Epub 2012/03/20; doi:10.1016/S0140-6736(11)61670-X; PubMed PMID: 22423872.

  8. MacKinney TG, Walters D, Bird GL, Nattinger AB. Improvements in Preventive Care and Communication for Deaf Patients: Results of a Novel Primary Health Care Program. J Gen Intern Med. 1995;10(3):133-7. Epub 1995/03/01; doi:10.1007/BF02599667; PubMed PMID: 7769469

  9. Barnett S. Cross-Cultural Communication With Patients Who Use American Sign Language. Fam Med. 2002;34(5):376-82.

  10. Panzer K, Park J, Pertz L, McKee MM. Teaming Together to Care For Our Deaf Patients: Insights From the Deaf Health Clinic. JADARA. 2020;53(2):60-77.

  11. The Americans with Disabilities Act. Communicating Effectively with People with Disabilities. ADA.gov. https://www.ada.gov/topics/effective-communication/. Accessed March 2025.

  12. U.S. Department of Health and Human Services. Section 1557: Ensuring Effective Communication With and Accessibility for Individuals with Disabilities. HHS. https://www.hhs.gov/civil-rights/for-individuals/section-1557/fs- disability/index.html. Reviewed August 25, 2016. Accessed March 2025.

  13. Northwest ADA Center. Healthcare and Face Coverings: Reducing Communication Barriers for Deaf and Hard of Hearing Patients. ADA National Network Information, Guidance, and Training on the Americans with Disabilities Act.

  14. U.S. Department of Health and Human Services. Language Access Provisions of the Final Rule Implementing Section 1557 of the Affordable Care Act. https://adata.org/factsheet/healthcare-and-face-coverings. Published 2021. Accessed March 2025.

  15. Certification Commission for Healthcare Interpreters. Get Certified With CCHI. CCHI website. https://cchicertification.org/. Updated 2025. Accessed March 2025.

  16. ​Agency for Healthcare Research and Quality. Teach-Back: Intervention. AHRQ. https://www.ahrq.gov/patient- safety/reports/engage/interventions/teachback.html. Reviewed June 2023. Accessed March 2025.

​Reports

Patient History Alerts Keep Staff Informed and Prepared
In some patients, anesthetics can cause a severe, sometimes lethal, reaction known as malignant hyperthermia (MH), with symptoms such as a dangerously high body temperature, rigid muscles or spasms, and a rapid heart rate. It is important to communicate a history of MH to  
operating room (OR) staff before a surgical procedure, but at one hospital in 2017, the surgeon’s office did not inform Scheduling, Anesthesia, or the OR of the patient’s history of MH. Fortunately, it was identified immediately preop and the team took appropriate precautions, resulting in no harm to the patient.

However the near miss prompted the Preadmission Center clinical leader and the OR operations manager to investigate the incident to prevent this from happening again, and the clinical risk coordinator referred the issue to the health information technology (Health IT) team and requested an alert to fire when a patient with a history or family history of MH is being planned for surgery. As a result, a multidisciplinary team comprised of Anesthesiology, Preadmission Testing, OR, Health IT, and Risk Management developed new case alerts in the electronic health record for MH.

These alerts fire warnings in the form of a patient alert banner (“Patient has a history of malignant hyperthermia.”) when a documented history of MH is entered for the patient, whether during scheduling or pre-anesthesia testing or visit, or by OR nurses, the surgeon, or anesthesia, with reminders to follow the facility’s procedures for notifying OR and Anesthesia leadership and update the case comments and medical record.

The Patient Safety Authority's 2024 Annual Report is now available, highlighting our commitment to safer care for Pennsylvanians. Some of last year's accomplishments:

  • We analyzed serious event reports identifying neonatal injuries or death related to labor and delivery, published our findings in a report, and shared evidence-based strategies for mitigating the risks associated with shoulder dystocia.
  • We worked with ambulatory surgical facilities to improve surgical site infection surveillance and reporting, including regional, in-person symposia throughout Pennsylvania on the identification of infection through the application of criteria and using hospital-acquired infection data to evaluate infection prevention programs.
  • We embarked on an ambitious five-year strategic plan, Reimagine Patient Safety 2029, built on three main pillars: push the boundaries of information science to identify and understand patient safety issues, leverage relationships to implement changes that improve patient safety, and maintain a strong organizational culture that focuses on people and continuous organizational improvement.
With over 5 million patient safety event reports, PA-PSRS is the largest repository of its kind in the United States and one of the largest in the world. See the full analysis of PA-PSRS data from 2024 in Patient Safety:

  • Patient Safety Trends in 2024: An Analysis of 315,418 Serious Events and Incidents From the Nation’s Largest Event Reporting Database
  • Long-Term Care Healthcare-Associated Infections in 2024: An Analysis of 26,501 Reports